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OBJECTIVES: To quantify the main reasons for referral of infants and children from first-level health facilities to referral hospitals in sub-Saharan Africa and to determine what further supplies, equipment, and legal empowerment might be needed to manage such children when referral is difficult. METHODS: In an observational study at first-level health facilities in Uganda, the United Republic of Tanzania, and Niger, over 3-5 months, we prospectively documented the diagnoses and severity of diseases in children using the standardized Integrated Management of Childhood Illness (IMCI) guidelines. We reviewed the facilities for supplies and equipment and examined the legal constraints of health personnel working at these facilities. FINDINGS: We studied 7195 children aged 2-59 months, of whom 691 (9.6%) were classified under a severe IMCI classification that required urgent referral to a hospital. Overall, 226 children had general danger signs, 292 had severe pneumonia or very severe disease, 104 were severely dehydrated, 31 had severe persistent diarrhoea, 207 were severely malnourished, and 98 had severe anaemia. Considerably more ill were 415 young infants aged one week to two months: nearly three-quarters of these required referral. Legal constraints and a lack of simple equipment (suction pumps, nebulizers, and oxygen concentrators) and supplies (nasogastric tubes and 50% glucose) could prevent health workers from dealing more appropriately with sick children when referral was not possible. CONCLUSION: When referral is difficult or impossible, some additional supplies and equipment, as well as provision of simple guidelines, may improve management of seriously ill infants and children.

OBJECTIVE: To investigate the problems, benefits, feasibility, and sustainability of implementation of WHO guidelines on management of severe malnutrition. METHODS: A postal survey invited staff from 12 African hospitals to participate in the study. Five hospitals were evaluated and two were selected to take part in the study: a district hospital in South Africa and a mission hospital in Ghana. At an initial visit, an experienced paediatrician reviewed the situation in the hospitals and introduced the principles of the guidelines through a participatory approach. During a second visit about six months later, the paediatrician reviewed the feasibility and sustainability of the introduced changes and helped find solutions to problems. At a final visit after one year, the paediatrician reassessed the overall situation. FINDINGS: Malnutrition management practices improved at both hospitals. Measures against hypoglycaemia, hypothermia, and infection were strengthened. Early, frequent feeding was established as a routine practice. Some micronutrients for inclusion in the diet were not locally available and needed to be imported. Problems were encountered with monitoring of weight gain and introducing a rehydration solution for malnutrition. CONCLUSION: Implementation of the main principles of the WHO guidelines on severe malnutrition was feasible, affordable, and sustainable at two African hospitals. The guidelines could be improved by including suggestions on how to adapt specific recommendations to local situations. The guidelines are well supported by experience and published reports, but more information is needed about some components and their impact on mortality.

OBJECTIVE: To describe the epidemiology of respiratory syncytial virus (RSV) infection in a developing country. METHODS: The work was carried out in three hospitals for primary cases and in the community for secondary cases in the western region of the Gambia, West Africa. RSV infection was diagnosed by immunofluorescence of nasopharyngeal aspirate samples in children younger than two years admitted to hospital with acute lower respiratory infection (ALRI). Routine records of all children with ALRI were analysed, and the incidence rates of ALRI, severe RSV-associated respiratory illness and hypoxaemic RSV infections were compared. A community-based study was undertaken to identify secondary cases and to obtain information about spread of the virus. FINDINGS: 4799 children with ALRI who were younger than two years and lived in the study area were admitted to the study hospitals: 421 had severe RSV-associated respiratory illness; 55 of these were hypoxaemic. Between 1994 and 1996, the observed incidence rate for ALRI in 100 children younger than one year living close to hospital was 9.6 cases per year; for severe RSV-associated respiratory illness 0.83; and for hypoxaemic RSV-associated respiratory illness 0.089. The proportion of all ALRI admissions due to RSV was 19%. Overall, 41% of children younger than five years in compounds in which cases lived and 42% in control compounds had evidence of RSV infection during the surveillance period. CONCLUSION: RSV is an important cause of ALRI leading to hospital admission in the Gambia. Morbidity is considerable and efforts at prevention are worthwhile.

Objective To compare oxygen supply options for health facilities in the Gambia and develop a decision-making algorithm for choosing oxygen delivery systems in Africa and the rest of the developing world. Methods Oxygen cylinders and concentrators were compared in terms of functionality and cost. Interviews with key informants using locally developed and adapted WHO instruments, operational assessments, cost-modelling and cost measurements were undertaken to determine whether oxygen cylinders or concentrators were the better choice. An algorithm and a software tool to guide the choice of oxygen delivery system were constructed. Findings In the Gambia, oxygen concentrators have significant advantages compared to cylinders where power is reliable; in other settings, cylinders are preferable as long as transporting them is feasible. Cylinder costs are greatly influenced by leakage, which is common, whereas concentrator costs are affected by the cost of power far more than by capital costs. Only two of 12 facilities in the Gambia were found suitable for concentrators; at the remaining 10 facilities, cylinders were the better option. Conclusion Neither concentrators nor cylinders are well suited to every situation, but a simple options assessment can determine which is better in each setting. Nationally this would result in improved supply and lower costs by comparison with conventional cylinders alone, although ensuring a reliable supply would remain a challenge. The decision algorithm and software tool designed for the Gambia could be applied in other developing countries. Objectif Comparer les options d'approvisionnement en oxygene qui s'offrent aux etablissements de soins de Gambie et developper un algorithme de prise de decisions pour guider le choix des systemes d'approvisionnement en oxygene en Afrique et dans le reste du monde en developpement. Methodes Les auteurs ont compare en termes de fonctionnalite et de cout les bouteilles et les concentrateurs d'oxygene. Ils ont interroge des informateurs cles en utilisant des instruments d'evaluation OMS mis au point et adaptes localement et realise des evaluations operationnelles, ainsi qu'une modelisation et des mesures des couts pour determiner le meilleur choix entre les bouteilles et les concentrateurs d'oxygene, lis ont elabore un algorithme et un outil logiciel pour guider la selection du systeme d'approvisionnement en oxygene. Resultats En Gambie, les concentrateurs d'oxygene presentent des avantages notables par rapport aux bouteilles lorsque I'alimentation electrique est fiable ; dans d'autres contextes, il est preferable de faire appel aux bouteilles dans la mesure ou leur transport est praticable. La presence de fuites, phenomene courant, influe fortement sur le cout des bouteilles, tandis que pour les concentrateurs, les couts energetiques sont de loin plus importants que les couts en capital. Sur les 12 etablissements gambiens, 2 seulement avaient interet d'apres l'etude a utiliser des concentrateurs ; pour les 10 autres, les bouteilles constituaient une meilleure option. Conclusion Ni les concentrateurs, ni les bouteilles ne conviennent a toutes les situations, mais une evaluation simple des options permet de determiner pour chaque contexte la meilleure solution. A l'echelle nationale, cette evaluation devrait conduire a une amelioration de I'approvisionnement et a une baisse des couts par rapport a la situation ou I'on utilise uniquement des bouteilles d'oxygene classiques, mais assurer un approvisionnement fiable devrait rester un defi. L'algorithme decisionnel et l'outil logiciel concus pour la Gambie devraient etre applicables dans d'autres pays en developpement. Objetivo Comparar las opciones de suministro de oxigeno para centros de salud en Gambia y desarrollar un algoritmo decisional para elegir los sistemas de suministro de oxigeno en Africa y en el resto del mundo en desarrollo. Metodos Se compararon la funcionalidad y el costo de las bombonas y los concentradores de oxigeno. Se Ilevaron a cabo entrevistas con informantes clave mediante instrumentos desarrollados localmente o adaptados a partir de otros de la OMS, evaluaciones operacionales, modelizaciones de costos y mediciones de costos a fin de determinar la mejor opcion entre las bombonas y los concentradores de oxigeno. Se desarrollo asi un algoritmo y un instrumento de software para fundamentar la eleccion dei sistema de suministro de oxigeno. Resultados En Gambia, los concentradores de oxigeno presentan ventajas importantes en comparacion con las bombonas alli donde el suministro electrico es fiable; en caso contrario, la opcion preferible son las bombonas, siempre y cuando sea factible transportarlas. El costo de las bombonas depende considerablemente de las fugas, un problema frecuente, mientras que el de los concentradores depende mucho mas del costo de la electricidad que de los gastos de infraestructura. Solo dos de los 12 centros de Gambia analizados reunian las condiciones idoneas para usar concentradores; en los otros diez centros, la mejor opcion eran las bombonas. Conclusion Ni los concentradores ni las bombonas son soluciones ideales para cualquier situacion, pero una simple evaluacion de esas dos opciones permite determinar cual es preferible en cada entorno. A nivel nacional, esa diferenciacion se traduciria en mejoras del suministro y menores costos en comparacion con el uso exclusivo de las bombonas convencionales, pero seguiria habiendo problemas para garantizar un suministro fiable. El algoritmo decisional y el instrumento de software concebidos para Gambia podrian aplicarse en otros paises en desarrollo., Introduction Acute respiratory infection, principally pneumonia, remains the leading cause of death in young children worldwide. (1-3) Case management of pneumonia is a key component of the WHO Integrated Management [...]

Abstract Background Quality hospital care is important in ensuring that the needs of severely ill children are met to avert child mortality. However, the quality of hospital care for children in developing countries has often been found poor. As the first step of a country road map for improving hospital care for children, we assessed the baseline situation with respect to the quality of care provided to children under-five years age in district and sub-district level hospitals in Bangladesh. Methods Using adapted World Health Organization (WHO) hospital assessment tools and standards, an assessment of 18 randomly selected district (n=6) and sub-district (n=12) hospitals was undertaken. Teams of trained assessors used direct case observation, record review, interviews, and Management Information System (MIS) data to assess the quality of clinical case management and monitoring; infrastructure, processes and hospital administration; essential hospital and laboratory supports, drugs and equipment. Results Findings demonstrate that the overall quality of care provided in these hospitals was poor. No hospital had a functioning triage system to prioritise those children most in need of immediate care. Laboratory supports and essential equipment were deficient. Only one hospital had all of the essential drugs for paediatric care. Less than a third of hospitals had a back-up power supply, and just under half had functioning arrangements for safe-drinking water. Clinical case management was found to be sub-optimal for prevalent illnesses, as was the quality of neonatal care. Conclusion Action is needed to improve the quality of paediatric care in hospital settings in Bangladesh, with a particular need to invest in improving newborn care.